The Cardiovascular Outcomes Research Center at Yale University will focus on research to promote hospital and regional excellence in patient outcomes and healthcare value. To accomplish this, the Yale team will leverage its expertise with the Centers for Medicare & Medicaid Services (CMS) outcomes measures; extend its pioneering work in positive deviance research and mixed methods approaches; build upon its longstanding collaborations with top outcomes researchers throughout the country; and engage with individuals and organizations capable of transforming the products of the research into practice. We will pursue two related research projects, and will leverage the Center to promote inter-institutional collaboration and the development of early stage investigators. Project 1 aims are: To characterize hospital and Hospital Referral Region (HRR) performance, assess time trends, and determine factors associated with performance and improvement, defined by the CMS publicly reported measures for acute myocardial infarction (AMI), heart failure (HF), percutaneous coronary intervention (PCI), and internal cardioverter defibrillators (ICD); to investigate hospital and regional performance using novel measures that focus on a longer episode of care (1-year mortality measures for patients hospitalized with AMI and HF) and population-based hospitalization rates (HRR hospitalization rates for AMI and HF); to characterize the costs of care for AMI and HF during the index hospitalization, in the first 30 days, and 1 year after admission; and investigate how costs and payments relate to hospital and regional performance (30-day and 1-year risk-standardized mortality and 30- day eadmission). Project 2 aims are: To develop hypotheses concerning the hospital organizational strategies associated with exceptionally low hospital-level risk-standardized 30-day mortality and readmission rates for patients undergoing PCI; and to survey hospitals in order to test hypotheses about which specific hospital organizational strategies are associated with better performance on these PCI outcomes. This project will involve a partnership with the American College of Cardiology's National Cardiovascular Data Registry, and will elucidate the organizational and clinical strategies associated with the best hospital performance for PCI patients. Together, these studies will respond to the need for evidence to guide efforts to improve care and better understand how to shift the curve of performance at the hospital and regional level toward better outcomes.